We report a case of 28-year-old male patient who was run over by train, which resulted in above-elbow amputation on the right side and hand amputation on the left side. His financial status precluded the use of upper limb prosthesis. In this report, we evaluated the various aspects of the Krukenberg operation. The parameters were functionality, stereognosis, cosmesis, dominance, patient and societal acceptance. In our country interest in Krukenburg operation should be rekindled. Most of the surgeons neglected it favor of expensive prosthesis on grounds of unfamiliarity with the surgical procedure.

The Krukenberg operation (an eponymous procedure) was first described in 1917. The incidence of hand amputation, bilateral or unilateral is more prevalent in war torn regions, because of anti-personnel mines. The explosive power of these devices has been diabolically reduced so that it will maim, but not kill the person. It is a known fact that a disabled person is the greater burden to society than a dead one. The patients we have come across were involved in industrial, road or rail accidents. Most of them when advised about the procedure were reluctant due to the fact that, they had adapted to the loss of the limb and used it as means of livelihood as beggers taking advantage of the "freak factor." Patient in this study accepted our surgical option, since both his hands were amputated, however with some reluctance.

Case Report

The present case report is about a 28-year-old male patient who was trying to board a train when he slipped and fell between the tracks and the platform. The train ran over his right arm and reflexly he put his left hand in order to protect the injured limb and in this process tragically injured his left hand also. The final result when he attended out-patient department 6 months after injury was an above-elbow amputation on the right side and wrist disarticulation on the left side [Figure 1] and [Figure 2].

He was unable to perform any activities of daily living (ADL) and was depressed. The cost of a functional prosthesis was beyond his means. The Krukenberg operation was offered to him and he was shown photographs from textbooks and journals. He was counseled regarding the extent of function that could be regained, keeping in view his age and the fact that it was the non-dominant left upper limb. The patient was selected as an extended indication for the operation for bilateral amputees even if they are not visible impaired. [1],[2],[3],[4]

Surgical technique

The classical procedure described by Swanson and Swanson was followed. [5],[6],[7]

A longitudinal incision was made on the flexor surface of the forearm slightly toward the radial side. A similar incision on the dorsal surface slightly toward the ulnar side, but on this surface a V-shaped flap to form a web at the junction of the rays was elevated.

The forearm muscles were separated into two groups. Pronator quadratus, flexor digitorum profundus (FDP), flexor pollicis longus, abductor pollicis longus and extensor pollicis brevis muscles, were resected in order to reduce the size of the stump. Utmost care was taken not to disturb the pronator teres.

Interosseous membrane was incised throughout its length along ulnar border, taking care not to damage the interosseous vessels and nerve [Figure 3]. Motion at their proximal ends occurs at the radiohumeral and proximal radio ulnar joints. The opposing ends of the rays should touch. The tourniquet was removed, hemostasis secured. Skin edges were opposed and sutured. About 15-20% of the area was covered with split skin graft. Wound closed over the drain [Figure 4].

A minimum 10-12 cm opening should be present between the pincers for optimal function (this is best achieved by detaching the interosseous membrane as proximal as possible)

The integrity of Pronator teres should be maintained at all costs, as it is the prime motor for the pincer (the other stabilizer is supinator)

Sufficient debulking of finger flexor (flexor digitorum superficialis and FDP) and extensors should be done in order to get maximum full thickness cover of pincers. [8],[9]

Post-operative protocol and rehabilitation

During the 1 st week, limb was immobilized to get 100% take up of graft, hence no physiotherapy was advised. Pincers were kept apart with a cotton spacer for the 1 st week until the graft was well taken (10-12 days). Patient was sent home with advice to open and close the pincers with abduction-adduction type of movement [Figure 5] and [Figure 6]. He was told specifically to avoid rolling the radius on to the ulna. [10],[11],[12]

After 4 weeks active rehabilitation was started. The aim of rehabilitation was to develop his grasp and pinch. Most of activities designed were goal oriented to make him independent in ADL. First he learned to grasp large object like tumbler of water [Figure 7] and [Figure 10] and later spoons with specially designed handles. As time progressed, he could grasp finer objects like spoons that are not modified [Figure 8] and sheet of paper [Figure 11]. These processes of rehabilitation took approximately 16-20 weeks and were directly proportion to the maturity of the stumps. Around 16 weeks, the patient was dexterous enough to hold a pen and start rudimentary writing [Figure 9]. Sequential muscle strengthening exercises were started until he was able to lift up to 10 kg. Regular assessment was performed every month for improvement.

This 28-years-old male patient was completely dependent for ADL, after sustaining above elbow amputation on the right side and disarticulation at the left wrist in a rail accident. Upper limb prosthesis is available in our country but is not within the reach of most of the effected population as they are manual workers. As treating doctors, we ourselves were sceptical about the outcome of this operation. In the recent past, it has become surgical rarity. The functional improvement after the operation allowed the patient to do most of his ADL, including the ability to dress himself independently with a minimal modification of his clothing. The other area of concerned was about how the non-dominant left upper limb would adapt. Literature suggests that shift of dominance is common in children. Whether the same would be applicable to adults was a big question on our minds. The patient in the study showed a rapid shift from being a right handed person from birth to a dominant left hand side Krukenberg pincer. This happened within a time frame of 16-24 weeks, which was much faster than the expected.

Conclusion

The Krukenberg operation is still a valid indication in our country. In bilateral amputees, the sensory motor feedback is essential for the patient. Even in adults rapid shift of dominance can take place within 16-24 weeks. This is the only case where time taken for a shift of dominance was studied.